The use of billed palliative care services among Medicare beneficiaries with hematologic malignancies has risen dramatically in recent years, but most encounters still occur within days of death, according to research presented at the 2019 Supportive Care in Oncology Symposium.1 The analysis of Medicare data found that less than 2% of patients received billed palliative care services more than 30 days prior to death. Although rare, these early palliative interventions were associated with better quality metrics for end-of-life care, similar to those observed in solid tumors, the study authors reported.
“Based on these data, I would encourage us all to consider early integration of palliative care into standard hematologic care,” said Vinay Rao, DO, a hospice and palliative medicine specialist at Rhode Island Hospital, Providence. “These results also support the need for prospective trials of early palliative care for patients with hematologic malignancies.”
As Dr. Rao reported, patients with hematologic malignancies often receive aggressive care at the end of life and frequently receive more aggressive care than patients with solid tumors. Although early palliative care may improve the quality of life and end-of-life care, he noted, its benefits are less established in patients with hematologic malignancies than in those with solid tumors.
Furthermore, studies measuring palliative care and the quality of end-of-life care are predominantly qualitative or limited to single-institution settings. There are no population-level studies examining the association between palliative care and the quality of end-of-life care in patients with hematologic malignancies.
For this study, Dr. Rao and colleagues used the Surveillance, Epidemiology, and End Results–Medicare linked registry to analyze Medicare beneficiaries diagnosed with leukemia, lymphoma, myeloma, myelodysplastic syndrome, or myeloproliferative neoplasm who died between 2001 and 2015. The researchers identified billed palliative care services using ICD-10 codes for clinician encounter claims and noted the type of health-care provider and the location of services. For patients who survived at least 30 days from diagnosis, the researchers compared baseline characteristics and the quality metrics of end-of-life care of the early-exposure cohort (patients with billed palliative care services initiated at least 30 days before death) with those of patients who did not receive early palliative care.
Of the 139,191 patients with hematologic malignancies included in the analysis (median age, 81 years), the frequency of palliative care consultations was low, regardless of timing, said Dr. Rao. Just 5.2% of patients received any billed palliative care service, and the majority of these encounters occurred late in the disease course.
As Dr. Rao reported, 58.0% of patients who had palliative care received their first billed service within 14 days of death, and another 13.5% received their first billed service between 15 and 30 days of death. The median time from the first palliative care encounter to death was 10 days, and 84.3% of consultations occurred during hospital admissions. Just 1.7% of patients of the total cohort had palliative care services initiated more than 30 days from death.
Based on these data, I would encourage us all to consider early integration of palliative care into standard hematologic care.— Vinay Rao, DO
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Despite these low numbers, however, the authors noted an exponential increase in the proportion of patients receiving palliative care services over time in both early- and later-exposure groups. The data also showed a shift in the specialties generating these claims.
“In 2001, the majority of these claims were generated by family medicine and internal medicine providers. However, there has been a relative decrease in general medicine claims and a relative increase in nurse practitioner and hospice and palliative medicine claims,” explained Dr. Rao.
Analysis of baseline characteristics showed that patients with acute leukemia had a higher frequency of early billed palliative care services than did patients who had other histology subtypes. Conversely, patients who were at least 80 years old had a lower frequency of early palliative care services. Female gender, black race, higher comorbidity index, poor performance status, and receipt of chemotherapy at any time after diagnosis were also associated with an increased frequency of early palliative care services.
Finally, receipt of early billed palliative care services was associated with improved quality metrics for end-of-life care. In general, said Dr. Rao, patients who had increased hospice utilization had a higher frequency of early palliative care consultations. On the other hand, patients who had more aggressive care in the form of emergency department visits, hospitalizations, intensive care admissions in the last 30 days of life, and chemotherapy use in the last 14 days of life had a relatively lower frequency of early billed palliative care services.
Problematic Nature of ICD Coding
In addition to the retrospective nature of the study, Dr. Rao acknowledged that ICD-10 codes can be problematic in the analysis of administrative data. Under this coding system, encounter for palliative care was intended to document “comfort care,” “terminal care,” and “end-of-life care” for reimbursement purposes and to reflect disease severity. With the rise of palliative care as a specialty, however, these codes are now used to document services such as goals-of-care conversations and symptom management as well.
“We really need to see improvements in ICD coding so we can better represent true palliative care services,” commented Dr. Rao. “I would also encourage all of us to conduct or promote patient participation in prospective trials looking at specialty palliative care services and specifically the quality of end-of-life care.” ■
DISCLOSURE: Dr. Rao reported no conflicts of interest.
1. Rao V, Olszewski A, Egan P, et al: Billed palliative care services and end-of-life care in patients with hematologic malignancies. 2019 Supportive Care in Oncology Symposium. Abstract 43. Presented October 26, 2019.
Discussant of the abstract by Rao et al, Oreofe Olukemi Odejide, MD, MPH, a medical oncologist at Dana-Farber Cancer Institute, Boston, underscored the issues associated with intense health-care utilization near the end of life. “Several studies have shown that intense health-care utilization...